Does this lung nodule need urgent review? A discrete choice experiment of Australian general practitioners

Abstract

Background: Lung cancer is the leading cause of cancer mortality in Australia. Guidelines suggest that patients with suspected lung cancer on thoracic imaging be referred for urgent specialist review. However, the term "suspected" is broad and includes the common finding of lung nodules, which often require periodic surveillance rather than urgent invasive investigation. The British Thoracic Society recommends that a lung nodule with a PanCan risk > 10% be considered for invasive investigation. This study aimed to assess which factors influence general practitioners (GPs) to request urgent review for a lung nodule and if these factors concur with PanCan risk prediction model variables. Methods: A discrete choice experiment was developed that produced 32 individual case vignettes. Each vignette contained eight variables, four of which form the parsimonious PanCan risk prediction model. Two additional vignettes were created that addressed haemoptysis with a normal chest computed tomography (CT) scan and isolated mediastinal lymphadenopathy. The survey was distributed to 4160 randomly selected Australian GPs and they were asked if the patients in the vignettes required urgent (less than two weeks) specialist review. Multivariate logistic regression identified factors associated with request for urgent review. Results: Completed surveys were received from 3.7% of participants, providing 152 surveys (1216 case vignettes) for analysis. The factors associated with request for urgent review were nodule spiculation (adj-OR 5.57, 95% CI 3.88-7.99, p < 0.0001), larger nodule size, presentation with haemoptysis (adj-OR 4.79, 95% CI 3.05-7.52, p < 0.0001) or weight loss (adj-OR 4.87, 95% CI 3.13-7.59, p < 0.0001), recommendation for urgent review by the reporting radiologist (adj-OR 4.68, 95% CI 2.86-7.65, p < 0.0001) and female GP gender (adj-OR 1.87, 95% CI 1.36-2.56, p 0.0001). In low risk lung nodules (PanCan risk < 10%), there was significant variability in perceived sense of urgency. Most GPs (83%) felt that a patient with haemoptysis and a normal chest CT scan did not require urgent specialist review but that a patient with isolated mediastinal lymphadenopathy did (75%). Conclusion: Future lung cancer investigation pathways may benefit from the addition of a risk prediction m9odel to reduce variations in referral behavior for low risk lung nodules.

Role of primary care physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review

“…The included quantitative studies consisted of 13 cross-sectional studies25 34–45 and two experimental studies,23 46 of which 11 used vignette-based methods;23 25 35–39 42 44–46 three were prospective cohort studies,47–49 and one was a retrospective cohort study (online supplemental material 2). 49 Qualitative data came from five interview studies,50–54 two focus group studies,55 56 two cross-sectional survey studies57 58 and one retrospective cohort of free-text primary care consultation data 59.…”

“…49 Qualitative data came from five interview studies,50–54 two focus group studies,55 56 two cross-sectional survey studies57 58 and one retrospective cohort of free-text primary care consultation data 59. Of these 29 included studies, 11 were conducted in the UK,23 25 34 37 43 44 50 51 54 55 57 six in Denmark,40 41 45 47 60 61 two across 20 countries within the European Union,39 58 two each in Australia,35 46 the USA,36 38 and Norway,49 53 and one each in the Netherlands,59 Sweden,52 Spain,56 and across Australia and the UK 42. Together, studies reflected a total of 10 300 PCPs (8000 from quantitative studies, 2300 from qualitative studies) and testing and referral decisions for 15 100 patients.…”

Systematic review and validity assessment of methods used in discrete choice experiments of primary healthcare professionals

“…The most common attribute used in the DCEs assessing physician preferences for therapy and disease was cost [ 19 , 20 , 22 , 28 , 29 , 31 ], including both cost of the intervention [ 20 , 22 , 28 , 29 , 31 ] and direct cost to the patient [ 19 , 20 , 29 , 31 ]. Other frequently used attributes included patient preferences [ 19 – 21 , 31 , 38 , 53 ], effectiveness of the intervention [ 19 , 20 , 29 – 31 ], health professional’s experience with either the patient or the intervention [ 20 , 23 , 29 , 31 , 53 ], and disease characteristics such as level of functional impairment or duration [ 21 , 24 , 25 , 32 , 53 ].…”

“…Fourteen of the studies assessed healthcare professional decision making about therapy and disease management [19][20][21][22][23][24][25][26][27][28][29][30][31][32], twelve assessed preferences for organisation characteristics of primary care practices [33][34][35][36][37][38][39][40][41][42][43][44], seven assessed the relative influence of implementation and knowledge translation strategies [45][46][47][48][49][50], and two assessed preferences for information and communication technologies [51,52].…”

“…Other frequently used attributes included patient preferences [19-21, 31, 38, 53], Fig. 1 PRISMA flow diagram of study selection [18] effectiveness of the intervention [19,20,[29][30][31], health professional's experience with either the patient or the intervention [20,23,29,31,53], and disease characteristics such as level of functional impairment or duration [21,24,25,32,53].…”